CONTRACTOR PERSONAL CONFLICTS OF INTEREST
FINANCIAL DISCLOSURE TEMPLATE
(OCT 2015)
Offerors/Contractors:
- Use of this actual template is not required. This template is provided as a sample for the kind of information CMS has found to be vital for proper personal COI analysis. If the offeror/contractor uses its own template or form for personal conflict of interest information collection and disclosure, the offeror/contractor should ensure that, at a minimum, the information captured on this template is collected.
- Personal Conflict of Interest Financial Disclosure information shall NOT BE submitted to CMS. However, such information shall be collected and analyzedfor all Governing Body members (e.g., Board of Directors, Trustees, etc.), and principals of the organization as defined by FAR 52.203-13, Contractor Code of Business Ethics and Conduct, and for each manager and key personnel who would be, or are involved with, the performance of the contract. NOTE: References to organizational and/or personal conflicts of interest will be referred to individually and collectively as conflicts of interest (COI).
- Compliance Officer Analysis. Offeror/Contractor Compliance Officer Analysis of Individual Personal Conflicts Of Interest is required – See end of this templatefor a sample of Reporting Employee Disclosureand analysis.
Reporting Employee (Also includes Board of Director members or others, as applicable):
- Please complete the “Reporting Employee Information”below that will identify you as the reporter. None of the below information will be submitted to the government; it is for internal collection and analysis only. However, if you have concerns regarding personal information requested in this Form, please consult with thecompany Compliance Officer.
- Read the instructions for Parts I through IV (Identified in Blue Headers)on the following pages.
- General Statements (Below Reporting Employee Information): Ifyouselected “Yes”foranystatement,youmustdescribethereportableinterestsinthecorresponding PartsI,II,III,and/or IV below in the Purple Header Sections. If additional space is required, please expand the space provided or provide additional pages.
- Sign and date the disclosure of information. Our Compliance Officer will retain this disclosure information and signature page on file.
- Submitcompleted documentsto ourCorporate Compliance Officer.
REPORTING EMPLOYEE INFORMATION
CompanyBusiness/Unit andAddress
Updated __ / Employee Identification
Reporting Status
Initial __ Annual __ Updated __
General Statements (Reporting Employee - Foreachstatementbelow,check“Yes”or“No.” For more detail or further instructions, see the following sections I thru IV below.) / Yes / No
- I have reportable assets or sources of income for myself, my spouse/domestic partner and/or any dependent of the respondent.
- I have reportable liabilities for myself, my spouse/domestic partner and/or any dependent of the respondent.
- I have reportable outside positions for myself, my spouse/domestic partner and/or any dependent of the respondent.
- I have reportablegifts and/or travel reimbursements for myself.
Part I: ASSETS AND INCOME
I.A. REPORTABLE ASSETSReportforYourself,Spouse/domestic partner and/or any dependent of the respondent: / DoNotReport:
•Healthcare Related Assetsheldfor investmentwithavaluegreaterthan$10,000 as of the date of disclosureORassetsheldforinvestment whichproducedmorethan$2,500inincome, including but not limited to:
Healthcare-related assets,suchas stocks,bonds,annuities,trustholdings, partnershipinterests,investmentreal estate,oraprivately-heldtradeorbusiness;
Healthcare sector mutualfunds(reportthefullnameofthe fund,notjustthegeneralfamilyfundname);
HoldingsofHealthcare Related self-directed retirementplans,suchas401(k)s, IRAs orSEPs(listeachholding);
DefinedbenefitpensionplansprovidedbyaHealthcare relatedformeremployer(includethenameof theemployer); and,
Type/location of healthcare related real estate. / •FederalGovernmentretirementbenefits
•Federal ThriftSavingsPlan.
•Certificatesof deposit,savingsorchecking accounts.
•LifeInsurance.
•Moneymarketmutualfundsandmoneymarket accounts.
•Yourpersonalresidence.
•Diversifiedmutualfunds,suchasABCEquity
ValueFundorXYZLargeCapitalFund.
•U.S.Federal/State/Local Governmentbonds,bills,notes,and savingsbonds.
•Moneyowedto you,yourspouse/domestic partner and/or dependentbyaspouse/domestic partner,parent,sibling,orchild.
I.B. HEALTHCARE-RELATED ANNUAL INCOME, ARRANGEMENTS OR AGREEMENTS
Report: / DoNotReport:
•ForYourself/yourSpouse/Domestic Partner and/or any Dependent of the respondent for all Healthcare Related :
Sourcesof salary,
Severance,
Bonuses,
Fees,
Commissions,
Honoraria, and
Otherearnedincome, arrangements or agreements, as well asothernon-investmentincomesuchas scholarships, patents, royalties, etc.
•For yourself only:
Continuingparticipationinanemployeepensionorbenefitplanmaintained byaformerHealthcare Relatedemployer;
Aleaveofabsence in order to perform duties for this present organization; and,
Known futureHealthcare Relatedemployment,includingdateyouacceptedemploymentoffer. / •Alimony and Child Support
•Veterans’benefits SocialSecurity or disabilitybenefits
•Any of the following for spouse/domestic partnerand/or any dependent of the respondent:
Continuingparticipationinanemployeepensionorbenefitplanmaintained byaformeremployer;
Aleaveofabsence to perform duties for this present organization; and,
Known futureemployment,includingdateyouacceptedemploymentoffer.
IMPORTANT DEFINITIONS
Diversified Mutual Fund – A mutual fund that does not have a stated policy of concentrating its investments in one industry, business, or single country other than the United States.
Sector Mutual Fund – A mutual fund that concentrates its investments in an industry, business, single country other than the United States, or bonds of a single state within the United States.
REPORTABLE ASSETS AND HEALTHCARE RELATED INCOME, ARRANGEMENTS OR AGREEMENTS
(I.A and I.B. Information should be provided in the white space below)
Notes: / When submitting information, please include the following specific information for reportable assets and income -
/ Healthcare related stock, bond, sector mutual fund, etc.: Please indicate the full name and dollar amount of each specific Healthcare related asset or investment. You may add the ticker symbol to the full name.
/ Healthcare related employer or business, source(s) of fees, commissions, or honoraria, please include the name and brief description of each, as applicable.
/ Healthcare related real estate investment, please include type/location for each.
/ You may distinguish any entry for a family member by preceding it with “S” for Spouse/Domestic Partner, “D” for Dependent, or “J” for Jointly held.
/ If additional space is required, please add an addendum to this disclosure.
Reportable Asset # / Description of Asset / $ Amount
1
2
3
4
Part II: LIABILITIES
ReportforYourself,Spouse/Domestic Partner and/or any Dependent of the respondent: / DoNotReport:•Loansover$10,000fromanindividual, suchasafriendorabusinessassociate who is employed by a Healthcare related entity or has a business association with a Healthcare related entity. / •Loansthatyouoweto your parent,spouse/domestic partner,sibling and/or any dependent.
REPORTABLE LIABILITIES
Nameofcreditor(includeCityandState wherecreditorislocated) / Typeofliability
1
2
3
PartIII:ADDITIONAL POSITIONS
ReportforYourself: / DoNotReport:- AllHealthcare relatedpositionsheldatanytimeduring the last 2 years,whetheror notyou werecompensatedORyoucurrentlyholdthatposition.Positionsincludeanofficer,director, employee,trustee,generalpartner,proprietor,representative,executor,or consultant of any of the followingHealthcare related concerns:
Non-profitorvolunteerorganization, and
Educationalinstitution (For instance, teaching hospital) /
- Any position with a
Social entity
Fraternal entity
- Anypositionheldbyyour
- Anypositionthatyouholdas part of yourcurrent officialduties
- Any positions reported in Part I.B
REPORTABLE POSITIONS
Organization(Includecityandstate whereorganizationislocated) / Position
1
2
3
4
Part IV: GIFTS AND/OR TRAVEL REIMBURSEMENTS
Report for Yourself, Spouse/Domestic Partner, and/or anyDependent of the Respondent: / DoNotReport:
•All non-employer Healthcare, travel-related reimbursements totaling more than $250 during the reporting period; include where you traveled, the purpose, and date(s) of the trip(s); and,
•Any gift(s) from Healthcare related companies with a fair market value totaling more than $250. /
- Anythingreceivedfromrelatives,theU.S.Government,D.C.,state,orlocalgovernments;
- Bequestsandotherformsofinheritance;
- Giftsandtravelreimbursementsprovidedby your organization inconnectionwithyourofficialtravel;
- Giftsofhospitality(food,lodging, entertainment)atthedonor’sresidenceor personalpremises; or,anythingreceivedbyyourspouse/domestic partnerand/or any dependent of the respondent, totallyindependentoftheir relationshipto you.
REPORTABLE INFORMATION
Source / Description
(For Travel, also include purpose of trip)
1
2
3
PERSONAL CONFLICTS OF INTEREST
FINANCIAL DISCLOSURE
EMPLOYEE SIGNATURE PAGE
(To Be Retained By Compliance Officer)
CERTIFICATION OF REPORTING EMPLOYEE:I, (Print Name), certifythatthestatementsI havemadeherein andon all attachmentsaretrue,complete,andcorrecttothe bestofmyknowledge.
Signature / Date(mm/dd/yy)
OFFEROR/CONTRACTOR COMPLIANCE OFFICER
ANALYSISOF INDIVIDUAL
PERSONAL CONFLICTS OF INTEREST
Description of Project:
- <Provide a summarized description of the work being performed on the CMS contract.
Potential Conflicts for this Project:
- Employee’s Role on Contract: <Provide a high level description of the employee’s role on the project. Be sure to de-identify any PII.
- Description of Conflict(s): <Provide a list of reportable interests that create an actual, apparentand/or potential conflict for the work described above in Description of Project.>
Compliance Officer Assessment: (If none, state “None”):
Provide the Compliance Officer’s assessment and determination of whether any conflict(s) exist that must be mitigated and how the conflict is/will be resolved.
(Checkhere ifcontinuedonadditionalpage(s) ___)
CORPORATE COMPLIANCE OFFICER REVIEW:To the best of my knowledge and belief,based on the information disclosed, all actual, potential and/or apparent COIs have been mitigated.
Name & Signature of Corporate Compliance Officer / Date (mm/dd/yy)
E-mailAddress / Phone Number
EXAMPLE:
Delete this Page in Submissions
OFFEROR/CONTRACTOR COMPLIANCE OFFICER
ANALYSIS OF INDIVIDUAL
PERSONAL CONFLICTS OF INTEREST
Description of Project: The Program Integrity contract is responsible for identifying fraud, waste and abuse in the Medicare Part A, B and HH+H in the state of Texas.
Potential Conflicts for this Project: It is the policy of XYZ to avoid situations that place officers, directors, managers, key employees in positions where their judgment may be biased in any way, or where their responsibilities may give them an unfair competitive advantage with respect to other business ventures.
- Provide a description of the employee’s role on the project: Employee #1 (Dr. John Smith has been de-identified) will work as the AB (Medical Director has been de-identified) on the contract. In doing so, Employee #1 will perform review of Medicare Part A, B and HH+H claims in the State of Texas.
- Provide a list of reportable activities that create an actual, apparent or potential conflict for the work described above in Description of Project:
- Provides or furnishes products and/or services that are billed to Medicare or Medicaid. Healthcare providers and suppliers include, but are not limited to, hospitals, doctors, skilled nursing facilities, home health agencies, ambulance companies, durable medical equipment companies, physical therapists, pharmacies, pharmacist, and clinical laboratories.
- Conducts audits of health benefit payments or cost reports, or conduct statistical analysis of health benefit utilization.
- Performs work of a Medicare Administrative Contract, Recovery Audit Contract or Qualified Independent Contractor.
Description of Conflict and Mitigation:
Employee #1 (Dr. Smith has been de-identified) has two conflicts that require a mitigation strategy. Employee #1’s financial disclosure revealed that the spouse (wife is de-identified) is a provider performing emergency room services in in Hospital XYZ located in Houston, TX and that Employee #1 has a position on the Board of QSR Medical Center located in Dallas, TX. The services being performed by Employee #1’s spouse at XYZ hospital may be reviewed under the contract. It is, therefore, determined that Employee #1 could or would be biased in any review of XYZ hospital. As a result, the mitigation is that Employee #1 must self-recuse from any and all work related to XYZ hospital. Regarding the position on the board of QRS Medical Center, Employee #1 could or would be biased in any review of services provided by QRS Medical Center. As a result, the mitigation is that Employee #1 must self-recuse from any and all work related to QRS Medical Center.
CONFIDENTIAL INFORMATION - NOT TO BE DISSEMINATED Page 1 of 9